Provider Demographics
NPI:1972193886
Name:GREEN, JESSI (NP)
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2163 S NOELTING WAY
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9289
Mailing Address - Country:US
Mailing Address - Phone:317-313-1260
Mailing Address - Fax:
Practice Address - Street 1:12400 N MERIDIAN ST STE 100
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4601
Practice Address - Country:US
Practice Address - Phone:317-559-3320
Practice Address - Fax:317-559-3321
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010851A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300048106Medicaid